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11/06/2002 15: 41 1916631 CASCADE DRILL INC <br /> 1t.ue2 : 4 ta:at 16 t aat uu a �rcutCASCcE DR PAGE 02 <br /> W uuc <br /> San Joaquin County Envtrertmental Health Department Unit IV welt permit Applioatiee Supplement <br /> JOB ADDRESS: f4G 2 PERMIT SA#: <br /> %r rc.a�3o.v yr �T- <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions o1 Chapter 9(eommanein9 with Section 7000)of Division <br /> 3 Of the Business and Profsasionns Code and my license Is In lull torte and eraw. <br /> License N: O Ezplrstien Dam: [ —3z—o I _ <br /> Data:: Contractor: <br /> Signature; /r _ _Title:QQQf?771 or.1 <br /> Printed name: le f�� C t:c M a r� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under oenahy of pariury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a cerllfkate Of Wnsont to self-Insurs for workers'compensation, as provided for <br /> by Section 3700 of the Labor Coda,for the performance of the work for which this permit Is Issued. <br /> I have and will maintain workers'compensation Insurance, as required by Section 3700 of the Labor Coda, <br /> for the performance of the work for which this permit is Issued. My workers'compensation insurance <br /> carrier and Policy numbers <br /> ,are, <br /> ' <br /> Carrier:1 162SKa /I/C27� d/I Ci/_ policy Number: O p�E LII S 3 0,&- <br /> I <br /> SI certify that;n the performance of the work for which this permit is issued, I shall not employ any person In <br /> any manner so as to become subject to the workers'compensation laws of Ca'Nornla, and agree that if <br /> should become subject to the workers'compensation prorsions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> I <br /> Onto; ��7_Signature: _' / <br /> Printed Name: V < �O� C Cc ,0�✓Loc.�. <br /> WARNING:FAILURE TO SECURE WORKERS'CONDENSATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> j AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FIN98 UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (6100,000.),IN ADDITION TOTHE COST OF COMPENSATION, IWTEREST, ATTORNEY'S FEES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> ' <br /> AUTHORIZATION FOR TH THAN C37 SIGNING PERMIT APPLICATION <br /> // <br /> I' Y e ra /n CE V,\— (signature ofC-5711wnsed authorized represenMiw), <br /> hereby authorite(print name) <br /> to sign trds Sen Joaquin County wail Permit Application on my beheM. I understand this authorisation is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this applleaben. <br /> 8.29-M/MI <br />